Dr. Iton’s commitment to improving the fundamental conditions of people’s lives is profoundly shaped by contrasting his experience of growing up in Montreal, Canada to the inequities he witnessed in the United States, when he moved to East Baltimore, Maryland to attend medical school. He found it problematic that health-promoting resources such as health care, childcare, and higher education were available to everyone in Canada, whereas he attended a world-renowned medical school that was situated in what he calls “one of the worst slums in America”. Boldly implicating power dynamics in the United States and working in partnership with communities to address structural poverty and institutional racism, fundamental factors that affect health, Dr. Iton is a clear public health hero. Currently, Dr. Iton is the Senior Vice President of the Healthy Communities initiative at the California Endowment. In this role, he and the Endowment partner with 14 communities in California to identify key priorities and to develop strategies with communities to design interventions and policy and systems change to make interventions more sustainable. Working in partnership with residents of low-income communities, Dr. Iton describes his work and partners as humbling, inspiring, exciting and fun. Summing up key players in efforts to eliminate health inequities, he explains, “it’s really about community and community’s selfless efforts to enhance other people’s lives, not just their own.”

Career in Profile

1981-1985 – Studied neurophysiology at McGill University

1985-1989 – Attended Johns Hopkins Medical School

1989-1990 – Intern at Cornell Medical Center/New York Hospital

1990-1993 – Attended the University of California, Berkley, Boalt Hall School of Law

1993-1994 – Staff Attorney/Health Policy Analyst, Consumers Union

1991-1996 – Primary care physician and advocate for the homeless, San Francisco Department of Public Health

NOW – Senior Vice President for Healthy Communities at The California Endowment

You are very open about the role of power dynamics and power differentials in posing a barrier to addressing structural influences on health inequities. In contrast, others in the area of racial and ethnic health inequities may not implicate power as a key cause of persistent health inequities although they definitely recognize that in their work and in their approach. Can you speak a little more about how you have come to understand these power dynamics and your approach to addressing this and why speaking so directly about it matters to you?

In my mind, we have everything that we need to know about what improves people’s health. We know people need to exercise. We know people need to eat healthy. We know that they need to have access to health care, particularly preventive health care. We know they need to have meaningful work and purpose in their lives. All of these things are known. It’s not like this is a mystery. We have so many people that are suffering from preventable illness because we don’t care enough about those people. We think that those people are less valuable than other people, because we have a national history of systematically devaluing certain populations. You don’t have to be a rocket scientist to see that we created an apartheid regime in this country that separated people by race and skin color and ethnicity. It systematically devalued their contributions and their ability to participate in processes.

When you walk into a place like East Baltimore and try to understand how this came to be, it doesn’t take very many steps to get to racial segregation. It’s stupid to pretend that just because segregation is now illegal, it doesn’t have a legacy. It lacks any form of critical thinking. So, if you acknowledge that there is a legacy to these past practices, and these past practices were based on a systematic devaluation of certain people based on their race or their skin color or their disability status, their immigration status, their sexual orientation – you name it – you recognize it plays out in policy to steer opportunity to preferred populations and away from despised populations.

Historically, the only way ever this changes is through a change in power dynamics. People do not yield privilege voluntarily. It has to be taken from them, through democratic processes designed to facilitate the sharing of power and the sharing of resources. I often refer to this work as “optimizing democratic processes,” because democratic processes are about balancing power. They’re just not working very well, in part because people with power are able to manipulate them. The only way to balance the scale is to organize people and marshal their collective power, within these democratic processes, to advocate for a different set of priorities and a different approach to sharing these resources.

This is about power. People need to understand what they’re looking at. People can dance all they want around this, but at the end of the day, if you’re serious about being effective in eliminating health disparities, then you have to understand the root causes of health disparities. The root causes of health disparities are power differentials that are rooted in present and past practices, as well as the legacy of those past practices. I don’t know what else to do to try to undo this. If you are serious about eliminating health disparities, yet you refuse to acknowledge the legacy of discrimination and segregation and the apartheid nature of this society that has differentially denied people access to basic resources like parks, grocery stores, decent schools and jobs, then honestly, I don’t know what you’re doing. It’s not eliminating health disparities. That much I can tell you. It may be something, but it’s not eliminating health disparities.

People sometimes pose this as white against black, white against brown, or gay against straight, or whatever. That’s not the right frame. I think the majority of Americans are essentially dispossessed of political power. As a result, white middle class Americans are unhealthy. It boils down to the stresses that people have to experience, on a day-to-day basis, to get from A to B. The commutes that people have to get through to their work, the fact that people have to worry about losing their health insurance if they lose their job or if they quit, the fact that it’s very difficult to afford to send your kid to college, the fact that finding decent child care is ridiculously expensive and inaccessible – all of these things are stressors in the lives of lower, middle, and upper middle class populations.

We have created this hyper-individualistic society which is fueled by this notion that government doesn’t matter and that the private sector will solve all problems. As I see it, the evidence speaks very much to the contrary. If you look at the health of middle class Americans compared to the health of wealthy Americans, you see life expectancy gaps on the order of 3 to 5 years. In terms of life expectancy, our wealthiest do about as well as Britain’s poorest. And I’m talking about whites. It’s absurd to argue that somehow our system is working for people’s health. The data say the exact opposite. It’s not just about race. It’s also about the stressors that we expose people to, ones involved in pursuing basic life resources that we all need to be healthy.

On that notion of there being so much more to do, can you talk about some of the pressing public health challenges related to the work that you do and what you see as the work that remains to be done?

The challenge that remains is the elephant in the room: the health care delivery system, and everyone’s fascination with trying to modify because they believe it is the vehicle for improving the health of this country. Reality suggests that even the highest performing health care delivery system is not going to make much of a dent in persistent health disparities and health inequities. I got into this work around health insurance and universal health care. That was once my passion. I still think it is important, but for other reasons. As I mentioned before, the stresses that people have to live with are the root causes of health disparities. The further down you are on the economic totem pole, the greater the amount of chronic stress you have to deal with. Access to health care is a contributing stressor in this society. So, if we can largely eliminate that stressor by facilitating people’s access to health care in a more reliable fashion, we will have done a good thing for people’s health independent of access to the doctor. I think it’s just going to relieve people’s stress.

I think it will also allow people to refocus their energies on these larger questions about inequity. I think that the election of Obama has done that. It’s been a resounding, declarative statement that progress is about creating a more inclusive society, not a less inclusive society. The notion of extreme individualism, us-versus-them thinking, has been rejected. There’s no way forward with a dynamic of “the privileged” and “the not privileged.” Those are the big challenges.

If I had to sum it up, the big challenges that remain are the core systems that determine people’s life chances. Which include the education system, and what communities physically look and feel like – undoing segregation, redlining, and the concentration of poverty. Those are the things that hold people back – being concentrated in adverse communities that are depleted of resources and educational systems that don’t facilitate a path out. Those are the big challenges for the 21st Century. They’re also competitive challenges for this country. Other countries recognized this long ago, and they made investments in their educational systems. They invested in systems that facilitate more equity at the community and place level.

All of those things (segregation, poverty) are not within the control of individuals. They’re within the control of society. Societal decision-making processes that are essentially askew in this country. That’s the question for public health: to understand why they’re so askew and what do we do about realigning them? How can we redirect our focus towards policies and practices that make it difficult for whole communities to participate in society? That’s the challenge of public health: to ask the right questions and to stop chasing everyone down with brochures to try to change their behaviors.

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